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PubMed2005

The changing face of healthcare worker perceptions on powered air-purifying respirators during the SARS outbreak.

OBJECTIVES: Before the advent of severe acute respiratory syndrome (SARS), use of the powered air-purifying respirator (PAPR) in the setting of pulmonary tuberculosis has been controversial. Data regarding health care worker (HCW) perceptions and problems encountered with the use of the PAPRs were lacking. METHODOLOGY: A questionnaire-based survey was conducted of HCWs who had used the PAPR in clinical practice during the SARS outbreak, when use of the PAPR was mandatory and widespread. Evaluations of the question of whether HCWs were receptive to the use of the PAPR and their perceptions of common problems that were encountered were made. Perceptions of comfort, ease of use, visual, hearing, breathing and speech impairment, perceived protection against SARS and usage preferences were recorded. RESULTS: Only a minority of respondents found the PAPR uncomfortable, despite some interference with communication. Despite its much higher cost, the majority (84%) preferred to use the PAPR rather than the N-95 respirator when treating suspected SARS patients. However, opinions were equally divided regarding its use when treating patients with pulmonary tuberculosis; with 51% being in favour. CONCLUSIONS: With the advent of highly contagious diseases that pose a major occupational hazard to HCWs, the use of the PAPR has become more acceptable in clinical practice.

Attitude of Health Personnel↗
PubMed2006

Nurse educators' perceived challenges in mandatory continuing nursing education.

AIM: This paper reports a study that leads to understanding challenges facing nurse educators implementing mandatory continuing nursing education in The People's Republic of China. BACKGROUND: Mandatory continuing nursing education was instituted to maintain and develop registered nurses' competence in the context of healthcare reform in China in 1996. However, there is an increasing complaint of credit-focused and teacher-centred learning in Chinese literature. Despite an increasing appeal to improve the learning situation, little consensus has been reached. By examining nurse educators' perceived challenges and their coping strategies in implementing mandatory continuing nursing education, this study illuminates the possibilities for reform in mandatory continuing nursing education. METHODS: Data were collected through in-depth interactive dialogues between the researcher and five nurse educators in five healthcare organizations in China, utilizing Gadamer's philosophical hermeneutics. FINDINGS: Three themes were found in this study described as finding a way to support nurses' competence within a constrained situation, reconciling credit requirements and representing all stakeholders' interests. CONCLUSIONS: A tension between the mandatory continuing nursing education policy and the context of implementing the policy can contribute to credit-focused and teacher-centred learning. Regular policy review and educational support for nurse educators are crucial aspects to improve mandatory continuing nursing education.

Adaptation, Psychological↗
PubMed2005

Assessing the case for mandatory folate fortification: policy-making in the face of scientific uncertainties.

This paper presents the view that policy-makers face scientific uncertainties in assessing the case for mandatory folate fortification as a policy response to epidemiological evidence of the relationship between folate and neural tube defects. Moreover, the resolution of these uncertainties is confounded by the under-resourced state of nutrition information systems in Australia and New Zealand. The uncertainties relate to potential risks and benefits associated with the intervention for the target group and the population in general. These risks and benefits reflect the mismatch between evidence and policy that arises when addressing a presumed genetic abnormality in at-risk individuals with an intervention that is population-wide in its scope. There is an urgent need to conduct ongoing national nutrition surveys and monitor and evaluate policy interventions to strengthen the capacity of nutrition information systems to inform decision-making for this current, and future, public health nutrition policy.

Australia↗
PubMed1987

AIDS now.

Explore the source record for details and available documents.

AIDS Serodiagnosis↗
PubMed2004

The genesis of public health ethics.

As bioethics emerged in the 1960s and 1970s and began to have enormous impacts on the practice of medicine and research--fuelled, by broad socio-political changes that gave rise to the struggles of women, African Americans, gay men and lesbians, and the antiauthoritarianism impulse that characterised the New Left in democratic capitalist societies--little attention was given to the question of the ethics of public health. This was all the more striking since the core values and practices of public health, often entailing the subordination of the individual for the common good, seemed opposed to the ideological impulses of bioethics. Of what relevance is autonomy-focused bioethics for public health, with its mix of justifications including those that are either implicitly or explicitly paternalistic or that seek to impose strictures on individuals and communities in the name of collective welfare? To examine the deep divide between the central commitments of bioethics and the values that animate the practice of public health, we focus on a series of controversies implicating the concepts of privacy, liberty, and paternalism. Recognising the role of moral values in decision-making was a signal contribution of bioethics in its formative period. Over the past three decades a broad array of perspectives emerged under the rubric of bioethics but individualism remains central. As we commence the process of shaping an ethics of public health, it is clear that bioethics is the wrong place to start when thinking about the balances required in defence of the public's health.

AIDS Serodiagnosis↗
PubMed2004

The impact of Medicaid managed care on pregnant women in Ohio: a cohort analysis.

OBJECTIVE: To examine the impact of mandatory HMO enrollment for Medicaid-covered pregnant women on prenatal care use, smoking, Cesarean section (C-section) use, and birth weight. DATA SOURCES/STUDY SETTING: Linked birth certificate and Medicaid enrollment data from July 1993 to June 1998 in 10 Ohio counties, 6 that implemented mandatory HMO enrollment, and 4 with low levels of voluntary enrollment (under 15 percent). Cuyahoga County (Cleveland) is analyzed separately; the other mandatory counties and the voluntary counties are grouped for analysis, due to small sample sizes. Study Design. Women serve as their own controls, which helps to overcome the bias from unmeasured variables such as health beliefs and behavior. Changes in key outcomes between the first and second birth are compared between women who reside in mandatory HMO enrollment counties and those in voluntary enrollment counties. County of residence is the primary indicator of managed care status, since, in Ohio, women are allowed to "opt out" of HMO enrollment in mandatory counties in certain circumstances, leading to selection. As a secondary analysis, we compare women according to their HMO enrollment status at the first and second birth. DATA COLLECTION/EXTRACTION METHODS: Linked birth certificate/enrollment data were used to identify 4,917 women with two deliveries covered by Medicaid, one prior to the implementation of mandatory HMO enrollment (mid-1996) and one following implementation. Data for individual births were linked over time using a scrambled maternal Medicaid identification number. PRINCIPAL FINDINGS: The effects of HMO enrollment on prenatal care use and smoking were confined to Cuyahoga County, Ohio's largest county. In Cuyahoga, the implementation of mandatory enrollment was related to a significant deterioration in the timing of initiation of care, but an improvement in the number of prenatal visits. In that county also, women who smoked in their first pregnancy were less likely to smoke during the second pregnancy, compared to women in voluntary counties. Women residing in all the mandatory counties were less likely to have a repeat C-section. There were no effects on infant birth weight. The effects of women's own managed care status were inconsistent depending on the outcome examined; an interpretation of these results is hampered by selection issues. Changes over time in outcomes, both positive and negative, were more pronounced for African American women. CONCLUSIONS: With careful implementation and attention to women's individual differences as in Ohio, outcomes for pregnant women may improve with Medicaid managed care implementation. Quality monitoring should continue as Medicaid managed care becomes more widespread. More research is needed to identify the types of health maintenance organization activities that lead to improved outcomes.

Adult↗
PubMed2006

The California Cost and Coverage Model: analyses of the financial impacts of benefit mandates for the California legislature.

OBJECTIVE: To produce cost estimates of proposed health insurance benefit mandates for the California legislature. DATA SOURCES: The 2001 California Health Interview Survey, 2002 Kaiser Family Foundation/Health Research and Education Trust California Employer Health Benefits Survey, Milliman Health Cost Guidelines, and ad hoc surveys of large health plans were used. STUDY DESIGN: We developed an actuarial model to estimate short-term (1 year) changes in utilization and total health care expenditures, including insurance premiums and out-of-pocket expenditures, if insurance mandates were enacted. This model includes baseline estimates of current coverage and total current expenditures for each proposed mandate. PRINCIPAL FINDINGS: Analysis of seven legislative proposals indicated 1-year increases in total health care expenditures among the insured population in California ranging from 0.006 to 0.200 percent. Even when proposed mandates were expected to reach a large target group, either utilization or cost was sufficiently low to keep total cost increases minimal. CONCLUSIONS: Our ability to develop a California-specific model to estimate the impacts of proposed mandates in a timely fashion provided California legislators during the 2004 legislative session with more-detailed coverage and cost information than is generally available to legislative bodies.

Actuarial Analysis↗
PubMed2006

An analysis of California Assembly Bill 2185: mandating coverage of pediatric asthma self-management training and education.

OBJECTIVE: To summarize for the California Legislature the evidence on the medical effectiveness of pediatric asthma self-management training and education (PASMTE), including the use of peak flow meters, spacers, and nebulizers and the impact that mandated coverage of these services and devices under Assembly Bill (AB) 2185 would have on total health care expenditures, monthly premiums, health services utilization, and the public's health. MEDICAL EFFECTIVENESS FINDINGS: The review of the literature finds that PASMTE is medically effective and has favorable effects on the health of children with symptomatic asthma, as well as reduces asthma-related emergency room visits and hospitalizations. There was inadequate evidence to assess the effectiveness of the three medical devices independently of PASMTE. COST AND UTILIZATION FINDINGS: One-hundred percent of children in health maintenance organization (HMO) plans in California are already covered for PASMTE, with fewer having coverage for the specific medical devices. However, despite full coverage of PASMTE in HMOs, these services are underutilized. We expect that the enactment of AB 2185 would increase utilization of PASMTE among children who are currently covered by 10 percent as a result of increased awareness of current coverage by all HMOs and increased awareness of the importance of these services. We estimate that this increased utilization by children who are already covered may result in a total statewide premiums increase of $170,000 or 0.006 percent, equal to one to two cents per member per month (PMPM). PUBLIC HEALTH FINDINGS: It is estimated that the public health impact of the mandate, as a result of new utilization of PASMTE by 10 percent of children who are already covered, would reduce the number of school days missed because of asthma per year by 158,000; the number of children reporting restricted activity days by 6,020; the number of emergency department visits by 350; and the number of hospitalizations by 1,105. LEGISLATIVE ACTION: AB 2185 passed the legislature after being amended six times. The bill as it was signed into law did not mandate coverage for PASMTE, as all HMOs in California presently reported covering these services. However, the bill retained the mandate for coverage of the three medical devices, as their coverage was not as universal across health plans.

Asthma↗
PubMed2006

A comparative analysis of mandated benefit laws, 1949-2002.

OBJECTIVE: To understand and compare the trends in mandated benefits laws in the United States. DATA SOURCES/STUDY SETTING: Mandated benefit laws enacted in 50 states and the District of Columbia for the period 1949-2002 were compiled from multiple published compendia. STUDY DESIGN: Laws that require private insurers and health plans to cover particular services, types of diseases, or care by specific providers in 50 states and the District of Columbia are compared for the period 1949-2002. Legislation is compared by year, by average and total frequency, by state, by type (provider, health care service, or preventive), and according to whether it requires coverage or an offer of coverage. DATA COLLECTION/EXTRACTION METHOD: Data from published tables were entered into a spreadsheet and analyzed using statistical software. PRINCIPAL FINDINGS: A total of 1,471 laws mandated coverage for 76 types of providers and services. The most common type of mandated coverage is for specific health care services (670 laws for 34 different services), followed by laws for services offered by specific professionals and other providers (507 mandated benefits laws for 25 types of providers), and coverage for specific preventive services (295 laws for 17 benefits). On average, a mandated benefit law has been adopted or significantly revised by 19 states, and each state has approximately 29 mandates. Only two benefits (minimum maternity stay and breast reconstruction) are mandated in all 51 jurisdictions and these were also federally mandated benefits. The mean number of total mandated benefit laws adopted or significantly revised per year was 17 per year in the 1970s, 36 per year in the 1980s, 59 per year in the 1990s, and 76 per year between 2000 and 2002. Since 1990, mandate adoption increased substantially, with around 55 percent of all mandated benefit laws enacted between 1990 and 2002. CONCLUSIONS: There was a large increase in the number of mandated benefits laws during the managed care "backlash" of the 1990s. Many states now use mandated benefits to prescribe not only what services and benefits would be provided but how, where, and when services will be provided.

Data Interpretation, Statistical↗
PubMed2006

State-mandated benefit review laws.

OBJECTIVE: To determine which states have laws that require the review of mandated health insurance benefits and describe the various approaches states take in reviewing mandated benefits, as stated in the mandated benefit review (MBR) laws. DATA SOURCES: We queried online databases of the individual state statutes and reviewed the state statutes and state legislative agendas for all 50 states and Washington, DC to identify those states with active MBR laws as of September 2004. STUDY DESIGN: We reviewed the identified MBR laws to catalog their various components. The components chosen for this analysis include: general review strategy, designated reviewers, time frame for conducting reviews, criteria used in the review, requirements to use actuaries, sources of funding, and state data collection systems. Two of the authors independently created analysis categories and coded the MBR laws to document details on the major components of the laws. PRINCIPAL FINDINGS: We identified 26 state MBR laws active as of September 2004. A majority of the MBR laws specified a prospective review approach and only one law used an exclusively retrospective review approach. A substantial amount of variation was found with regards to the designated reviewers, time frames for conducting reviews, and criteria used in the review. Few states specified the use of actuaries, sources of funding, and state data collection systems. CONCLUSIONS: The number of states that have enacted MBR laws has increased substantially in recent years, however, different states have structured the review of mandated benefits differently, according to the values and perceived needs of the state legislatures. It is important that states increasingly consider a broader scope of review criteria so state decision makers can position themselves to mandate only those benefits that add real value to the state's health care system.

Insurance Benefits↗
PubMed1993

Functional status care categories and national health policy.

Our society clearly needs to set limits on health care. The United States health care delivery system is the fourth largest economy in the world, yet its inflation continues to grow at twice the normal rate of other products and services. The inefficiencies are built in in such a way that while intensive care beds are plentiful, and very expensive, 37 million Americans cannot gain access to health care because they are either uninsured or underinsured. It is estimated that this figure will approach 39 million by the end of the decade. Since many of these individuals are young, the problem, it is said, has no real practical consequences because the young are relatively healthy. Yet evidence exists that the uninsured and underinsured receive poorer care than covered individuals. This and other inequities in the system have led many thinkers like Leonard Fleck to ask how just we must be in society. The answer to this question would presumably help us determine the lengths we must go in correcting the inequities. Even if the peace-dividend emerges from the new political events around the world, and we are able to spend more of our money on health care, our resources are not a bottomless pit. If need alone drives the system, just performing open-heart surgery on everyone who needs it would cost more than the annual budget itself. Virtually everyone agrees, then, that escalating health care costs are a moral problem because justice is involved, a political problem because public interest is involved, and that limits must be set that are moral and public.

Activities of Daily Living↗
PubMed2005

Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment.

OBJECTIVES: To test whether nationally required drug use reviews reduce exposure to inappropriate medications in nursing homes. DESIGN: Quasi-experimental, longitudinal study. SETTING: Data source is the 1997-2000 Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries. PARTICIPANTS: Nationally representative population sample of 8 million nursing home (NH) residents (unweighted n=2,242) and a comparative group of 2 million assisted living facility (ALF) residents (unweighted n=664). MEASUREMENTS: Prevalence and incident use of 38 potentially inappropriate medications compared before and after the policy: 32 restricted for all NH residents and six for residents with certain conditions. Inappropriate medications were stratified by potential for legitimate exceptions: always avoid, rarely appropriate, or some acceptable indications. RESULTS: In July 1999, the Centers for Medicare and Medicaid Services (CMS) mandated expansions to the drug use review policy for nursing home certification. Using explicit criteria, surveyors and consultant pharmacists must evaluate resident records for potentially inappropriate medication exposures and related adverse drug reactions. Nursing homes in noncompliance may receive citations for deficient care. Before the CMS policy, 28.8% (95% confidence interval (CI)=27.3-30.3) of Medicare beneficiaries in NHs and 22.4% (95% CI=19.8-25.0) in ALFs received potentially inappropriate medications. Nearly all prepolicy use came from medications with some acceptable indications: 23.4% in NHs (95% CI=20.4-26.4) and 18.0% in ALFs (95% CI=15.6-20.4). After the policy, exposures in NHs declined to 25.6% (95% CI=24.1-27.1, P<.05), but similar declines occurred in ALFs (19.0%, 95% CI=16.7-21.3, nonsignificant). Postpolicy use of inappropriate medications with exempted indications remained high, and more than half was incident use: 20.6% of NH residents (95% CI=19.0-22.0) and 15.6% of ALF residents (95% CI=15.2-15.7). Use of drugs that are restricted with certain diseases increased 33% in NHs between 1997 and 2000 (from 9.3% to 13.2%; P<.05). Multivariate results detected no postpolicy differences in inappropriate drug use between long-term care facilities with mandatory drug use reviews and those without. CONCLUSION: Some postpolicy declines were noted in NH use of potentially inappropriate medications, but the decrease was uneven and could not be attributed to the national drug use reviews. This study is the first evaluation of the CMS policy, and it highlights the unclear effectiveness of drug use reviews to improve patient safety in NHs even though state and federal agencies have widely adopted this strategy.

Aged↗